The "Childmyths" blog is a spin-off of Jean Mercer's book "Thinking Critically About Child Development: Examining Myths & Misunderstandings"(Sage, 2015; third edition). The blog focuses on parsing mistaken beliefs that can influence people's decisions about childrearing-- for example, beliefs about day care, about punishment, about child psychotherapies, and about adoption.
See also http://thestudyofnonsense.blogspot.com

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Concerned About Unconventional Mental Health Interventions?

Thursday, February 21, 2013

I got up at 4 o’clock this morning to go to a TV
studio and be linked to a Russian Channel 1 program (“Life with Mikhail
Zelensky”) focused on the deaths of Russian children adopted by parents in the
United States. As it turned out, the birth parents of Maxim Shatto, the three-year-old
recently killed in Texas, were interviewed on the program, and told a rather
sad and somewhat sordid story of having left two young children with a
grandmother who may have been a poor choice of caregiver, with the subsequent
taking of the children into care and placement for adoption. (I only know this
because of the services of Alexander the simultaneous translator, who was
speaking into my ear while shouting and periodic applause filled the Russian
studio.) You can see this at http://www.youtube.com/watch?v=BcBXI2oTN6g&feature=share.

There is so little information available about Maxim’s
death that I cannot possibly say what lay behind this event. I was asked to describe
attachment therapy for the program, and did so, but I was not asked whether I
thought Maxim had been subjected to any aspect of that unconventional treatment.
Again, I cannot think either way about this until I know much more. I am
curious as to whether the little boy had failed to gain weight in his adoptive
home, because this suggests the use of parenting techniques advised by AT
proponents. I was also asked about restrictions on prescription of Risperdal,
the adult psychotropic medication that Maxim is said to have been taking, and I
was able to say that there is little control over these off-label
prescriptions.

But of course these are not all the things I would
have liked the chance to say. Although I am very concerned about misinformation
given to adoptive parents about attachment and about appropriate mental health treatment
for adopted children, and although such misinformation may be most directly
responsible for mistreatment of children, the picture is obviously much bigger
than this. The absence of other information may drive adoptive parents to
over-reliance on questionable mental health advice.

Aren’t all adoptive parents supposed to have some
hours of pre-adoption education according to the Hague convention? Yes, they
are, but there is no clear statement about what those hours cover. I understand
that some programs concentrate on “scrap-booking” about the children’s lives-- a fine thing to do together, but not a matter
that takes long to explain. The change.org petition I mentioned recently wanted
pre-adoptive parents to be told that children with Reactive Attachment Disorder
were likely to be violent and dangerous, and this request suggests to me that
perhaps some pre-adoption programs already hand out this inaccurate claim.

What would be some good things to include in
pre-adoption education? One topic I’d like to see covered would be the problems
that children adopted from institution abroad are actually likely to have.
These include difficulties with attention and distractibility, as well as with
the “executive function” that allows a person to make decisions about what to
do, including stopping a course of action that was undertaken by mistake or judged
to be wrong after it is begun. In addition, post-institutional children are likely
to have language delays and to need speech therapy. (Language delays are the
source of many behavior problems, because a child who cannot understand what he’s
told, and who can’t explain his problems, is quite likely to be frustrated to
the point of tantrums or other displays of distressed emotions.)

What is the purpose of telling pre-adoptive parents
these things? One is to clarify for them that emotional or behavior problems
displayed by an adopted child may have to do with more than his or her
emotional development. They may occur in connection with cognitive or language
delays that are not necessarily obvious to the casual observer.

A second point of giving this information-- and this, I think, is essential-- is to allow pre-adoptive parents to look for
and arrange appropriate services in the area where they live, or to discover
(better now than later) that getting such services may require extensive
travel. For example, in how many parts of the U.S. can people find a bilingual,
Russian/English, speech therapist to work with a child whose English is very
limited and whose Russian may be delayed? In how many areas can people find a
therapist who can do Parent-Child Interaction Therapy, an evidence-based
treatment that helps parents and children communicate and decreases
oppositional behavior? If the parents cannot get access to these post-adoption services,
will they find themselves limited to practitioners who use heavy-duty
medication to stop “difficult” behavior? Information given to the pre-adoptive
parents early-- and given consideration
by the adoption caseworker—can make the difference between desperation and good
functioning in the months to come.

Let’s back up a bit, though. I’ve just mentioned
that the caseworker should have some idea what resources are needed and will be
available to the adoptive family. This brings up the likelihood that abusive
adoptive parents (like abusive non-adoptive parents) are not just “bad people” who
should have been screened out to begin with. Like many events in life, abusive
behavior toward children is probably determined by the interaction of multiple
risk factors, like an absence of resources. If there are few such factors,
abuse is unlikely; with addition of factors, it becomes more and more probable.
Adoption caseworkers need to look at a whole list of such risk factors, not
simply a checklist that shows whether the parent candidates are acceptable.

If a child will have many needs for professional
services, and the family lives at some distance from services, that is a risk
factor.

If one or both parents have a history of depression
and have limited access to treatment, that is a second risk factor. (Just as
perinatal mood disorders can be a factor in a birth mother’s abuse or neglect
of a child, parents with a history of depression may respond to adoption with
depression and inappropriate behavior.)

If the family is socially isolated, this is a risk factor.
Planning to homeschool may or may not indicate social isolation, but this
should be considered as a possibility interpretation.

If there are already many children in the home, if
the parents have fostered many children, or if the parents are adopting more
than one child at a time--
counter-intuitively, these are all risk factors that should be
considered by caseworkers, because they may indicate problems with individual
relationships with children, rather than the “wonderful self-sacrificing nature”
so sentimentalized by the mass media.

If the potential adoptive parents believe that their
primary job is to make the children obedient, this is a risk factor.

Again, we are talking about identifying risk factors
for abuse of adopted children. No single one of these or many other possible factors
means that an adopted child will be mistreated. Even if they are all present, abuse
or neglect will not necessarily be the outcome. But as risk factors are added,
and as family stresses like illness or unemployment unpredictably occur, the
results may be abusive treatment, of either the systematic kind advocated by
some proponents of attachment therapy, or plain old, unsystematic, common or
garden maltreatment.

We can make use of information about risk factors to
do a better job of screening potential adoptive parents. We can improve matters
by better pre-adoption education of those who are not screened out. But forgive
my cynicism if I say that we probably won’t, as long as the adoption industry
makes money both inside and outside the United States.

PLEASE NOTE: A longer Russian TV discussion of the use of attachment therapy can be seen at http://www.1tv.ru/news/world/227626. You will need to type this in, not click on it here.

Thursday, February 14, 2013

When those change.org petitions come around, it’s so
hard not to sign them. They all sound good and deserving. But, of course, there’s
nothing to stop petitioners from presenting inaccurate information and asking
for help with a matter that is to their own benefit alone. Such seems to be the
case with http://www.change.org/petitions/the-president-of-the-united-states-post-adoptive-support-for-children-with-reactive-attachment-disorder.
The group posting this petition, Hopefor Healing (spacing sic), has made a series of inaccurate statements and in addition
has implied that other wrong information is correct. I hope you will not sign
this petition, no matter what its emotional appeal may be.

The basic ideas stated in the “RAD” petition are the
following: 1) undesirable behaviors of adoptees may not be displayed until the
adoption process is over; 2) these behaviors, referred to as Reactive
Attachment Disorder, are highly disturbing and dangerous, and need highly
specialized treatment from residential facilities that focus on RAD; 3) parents
cannot afford to pay for treatment; 4) parents who relinquish custody of their
children voluntarily may be prosecuted, but should be allowed to relinquish
quickly; 5) pre-adoptive education
should include warnings of the potential of the child for violent behavior; 6)
post-adoptive services should include residential treatment for RAD (at least
this is my interpretation of the words “escalated to the highest levels of care”).

Before examining these claims under a strong light,
I want to refer to a related issue of genuine concern. As was pointed out in
the Bazelon Center for Mental Health Law’s 2000 publication Relinquishing Custody, state laws vary
on provision of mental health services for children. In some states, parents
may be forced to relinquish custody of a mentally ill child to the state before
treatment can be provided without charge--
a conclusion that most parents resist as long as they can. This very
real problem does not appear to be what “Hopefor Healing” is talking about.
They want children’s mental health interventions, as they define and desire them, to be provided at public expense,
and they also want to be able to relinquish custody quickly and easily.

But let’s look at “Hopefor’s” points one by one.
First, the idea that worrisome behaviors of adoptees are somehow concealed
until the adoption is final. According to the long-term research done by
Michael Rutter and the English-Romanian Adoptees project, children who had been
in the worst of worst conditions as infants and toddlers improved gradually
with time in the adoptive family, leading to the conclusion that adoption is one of the most effective developmental
interventions. Among the ERA children, even those who were seen as disinhibited
and too ready to go with strangers were by their teens regarded as friendly,
outgoing, popular kids. I should point out too that in the ERA study, the most
common problem was delayed language development, which was certainly present
when the adoption was initiated.

Second, what about the idea that the children are
likely to show violent, even homicidal behavior, and that this is evidence of
Reactive Attachment Disorder and should be treated as such? There are two
separate issues here. Yes, of course, as is the case in any population, some
adopted children may be callous and unemotional in behavior and/or may be
violently aggressive. However, as Charles Zeanah, the eminent child psychiatrist,
has made clear in his discussion of Reactive Attachment Disorder in preparation
for the DSM-5 publication (www.dsm5.org/Proposed%20Revision%20Attachments?APA%20DSM-5%20Reactive%20Attachment%20Disorder%20Review.pdf)
, in fact these characteristics are not associated with Reactive Attachment
Disorder. Thus, even if there were an evidence-based treatment for Reactive
Attachment Disorder, it would not be relevant to these cases-- and the fact is that organizations that claim
to specialize in treating RAD do not use methods of demonstrated effectiveness.
“Hopefor” is asking for children to be publicly funded for treatment that is
probably inappropriate for them, as well as lacking in an evidence basis.

Third, it is no doubt true that parents cannot
afford to pay for expensive, intensive treatment, and as the Bazelon Center
document suggested, we as a society need to correct this problem. However, it
will never be appropriate for parents to demand payment for an intervention
chosen by them on the basis of their beliefs about the child’s diagnosis, nor
will it be appropriate for anyone but an independent evaluator to make such a
diagnosis. Caseworkers from an adoption agency and prospective therapists are
not the right people to make these decisions. Even if resources were not
scarce, we would need to require independent assessments and avoid the apparent
confusion of “Hopefor” about the nature and treatment of Reactive Attachment
Disorder.

Fourth, although parents who abandon their children
may be prosecuted, those who relinquish legally are not (although they may be
called upon to repay funds that have been used to care for the child). States
have procedures for legal relinquishment that may involve counseling and discussion
of possible consequences, as well as providing simplified procedures and “safe
havens” for relinquishment of young babies. In practice, also, voluntary
relinquishment may be made very simple. In one case in which I testified, a
couple adopting from Russia had been persuaded to take a girl as well as the
boy they wanted. They did not like the girl much, placed her in attachment
therapy, and often sent her to a respite home for periods of time. Finally,
they decided they wanted to disrupt her adoption, and the respite family was
willing to adopt; this exchange was maneuvered by the caseworkers without the
usual formalities. When the girl was apparently mistreated in the new home and
the authorities were notified, the family sent her to a boarding school in
another state, a school that has been investigated for the use of restraint
with children and has argued that this is permissible. There she remains, probably
until she ages out at 18, and there has been no prosecution of the original
adoptive parents.

The fifth point, the demand that pre-adoption
counseling include the claims about violent and abusive behavior as a part of
Reactive Attachment Disorder, may be the real focus of this petition. According
to the Hague convention, to which the U.S. is a signatory, candidates for
adoptive parenthood must receive a number of hours of pre-adoption education.
At this point, the nature and provision of those hours are up to the adoption
agency involved. Even the Russia-U.S. adoption agreement of last year (now in
abeyance) did not outline the pre-adoption education required. This means that-- as most agencies do not have the time or
resources to write their own curricula--
it would be much to the advantage of any interested person to seize the
opportunity to write and market educational material. And if this material
informed prospective adoptive parents that their children might be dangerous,
that the danger was due to RAD, and that only specialized RAD treatment centers
could help-- why, so much the more
advantageous for the whole group that pushes misinformation about adoption and
attachment.

And, sixth, as above-- the petition essentially presses the claims
that there is only one set of problems, one diagnosis, and one treatment that
must be part of post-adoption services--
the treatment apparently being the complementary-and-alternative,
non-evidence-based approach often called Attachment Therapy, an intrusive,
time-consuming intervention that is not reimbursed by third-part payers, and
for good reason. But what could be better for its practitioners than being able
to do an end run around public and private health insurance and have public
funds support them in style?

Saturday, February 9, 2013

Many posts on this blog have been dedicated to
explaining that Reactive Attachment Disorder does not include various
disturbing traits described on websites such as www.attachmentdisorder.net.
Whereas Reactive Attachment Disorder includes unusual behavior with respect to
other people, including both clinging to caregivers and failing to prefer
caregivers to strangers, the characteristics often incorrectly attributed to
RAD include control battles, defiance, refusal of affection to caregivers, frequent
temper tantrums or “rages”, physical attacks on others, cruelty to animals and
smaller children, and so on.

Although some anxious caregivers easily interpret
any noncompliance as pathological, of course there are a small number of
children whose behavior really is disturbing, uncontrollable, and violent. Not
only are adults afraid that these children will harm others (including the
adults themselves), they also worry that the children’s apparent lack of
empathy for others will continue into adulthood, causing them to be a danger to
society and eventually to receive serious punishment for their actions. The adults’ beliefs about the causes and
solutions of these behavior problems makes them look for treatments like
Attachment Therapy, and like the associated Love & Logic program, that are
presented as appropriate therapies for unruly children.

But if violent and disturbing child behavior is not
caused by problems of attachment—is not really any form of “attachment disorder”—trying
to treat attachment is not likely to have much effect on them. Is there a more
constructive way to think about the child who is described at www.attachmentdisorder.net? And
can thinking in a different way guide us to more suitable treatments?

One useful approach has been to look at children who
have callous-unemotional (CU) traits.
Children classified in this way are described as lacking guilt and empathy,
being very egocentric, making use of others for the child’s own gain, and
lacking normal emotionality, especially normal anxiety (Herpers, Rommelse,
Bons, Buitelaar, & Scheepers, Social
Psychiatry and Psychiatric Epidemiology,2012, 47, 2045-2064). There is no clear agreement about whether these
characteristics should yield a diagnosis in themselves or whether they cross
the lines of various other diagnostic categories, but it is potentially very
valuable to define these problems by themselves and to move away from the idea
that all such troubles stem from attachment difficulties and can be cured by
improving attachment. (It’s interesting, by the way, that in 9 or 10 recent
professional articles on CU traits, although there was discussion of CU as a
part of Oppositional and Defiant Disorder [ODD] and of other diagnoses, no
author considered whether CU was part of RAD,and only one referred to an
attachment status, disorganized attachment in early life, as a factor in
bringing about CU traits.)

In looking at mental health issues, it is often
constructive to think about mood and behavior problems transactionally. This
means that mood and behavior of an individual are shaped by factors in the
individual and also factors in the environment, certainly including the
attitudes and actions of other people; it also means that as an individual matures
and learns, the effects of transactions with other people can also change.
Taking a transactional point of view, we can look at some characteristics that
are thought to be typical of children with CU behavior (as discussed in the
Herpers et al paper). Such children may have less anxiety than most people do,
and may focus more on rewards they get from their behaviors than on possible
punishing consequences, as well as having more trouble than most people in
recognizing others’ emotional expressions, especially fear. The transactional approach
suggests that, given the CU children’s unusual characteristics, they may
respond differently to parenting methods than more typical children would.
Parent training programs may be the best approach to treatment for children
with CU behavior. Significantly, research on use of restraint and seclusion in
child psychiatric programs suggests that reducing these methods is followed by
a reduction in violent behavior (Stellwagen & Kerig, Journal of Child and Family Studies,2010,19, 588-595), and this may generalize to parenting practices as
well.

One such program, Collaborative Problem Solving, developed by R.W. Greene and described in his 2008 book Lost
at school, emphasizes the importance of taking a proactive approach to
child behavior problems and to making the child an active partner in this
endeavor. Rather than focusing on consequences for undesirable behavior, Greene’s
CPS approach has child and adult working together to set priorities for what
needs to happen, to identify and develop needed skills before the next time they
are needed, and to consider situational and trigger factors that make it
difficult for the child to control impulses. Attachment is not mentioned—but working
together toward shared goals is one of the most important ways for human beings
to create social bonds, so a developmentally-appropriate form of attachment may
come in the back door as this method is put to work.

Greene stresses two important issues: the need for
the adult to exercise genuine empathy and understanding of the child’s needs,
and the fact that children who do not do as they are told most often cannot do
as they are told, at least not at that time and place. Adults who assume that
they must force a child to obey because the child is simply oppositional are
missing a real empathic understanding of the child’s experience, and thus they
create a transactional process with the child that takes both of them in an unwanted
direction.

In Lost at
school, Greene answers some questions about comparisons to other parent training
programs directed at helping with oppositional or CU behavior. One comparison
is between CPS and “Love & Logic”, the commercially-successful program sold
to hundreds of school systems and other groups. Foster Cline, one of the forces
behind “Love & Logic”, was of course an early practitioner of Holding
Therapy/Rage Reduction Therapy/Attachment Therapy. In commenting on “Love &
Logic”, Greene says “The Love and Logic program does place an emphasis on empathizing
with kids, but the empathy utilized in this program is primarily of the
emergent and perfunctory variety, isn’t aimed at gathering information or
understanding kids’ concerns, and is typically a prelude to Plan A [this is
Greene’s term for responding to a problem by imposing the adult’s will]. The
problem-solving that takes place between kids and adults in this program isn’t
aimed at reaching mutually satisfactory solutions. And the Love and Logic
program relies heavily on adult-imposed consequences” (p.200)-- consequences, as I noted earlier, that may
not be responded to by children with CU tendencies. Incidentally, although
Greene does not mention this, Love & Logic has not been subjected to outcome
research, whereas CPS has.

About Me https://en.wikipedia.org/wiki/Jean_Mercer

Jean Mercer has a Ph.D in Psychology from Brandeis University, earned when that institution was 20 years old (you do the math). She is Professor Emerita of Psychology at Richard Stockton College, where for many years she taught developmental psychology, research methods, perception, and history of psychology. Since about 2000 her focus has been on potentially dangerous child psychotherapies, and she has published several related books and a number of articles in professional journals.
Her CV can be seen at http://childmyths.blogspot.com/2009/12/curriculum-vitae-jean.mercer-richard.html.